title: Thromboelastography in the assessment of bleeding following surgery for congenital heart disease.
abstract: BACKGROUND
  Perioperative bleeding is common in pediatric cardiac surgery patients. Traditional laboratory tests do not adequately characterize coagulation derangements in patients with bleeding. We sought to establish preoperative thromboelastography parameters in children prior to cardiopulmonary bypass, to compare thromboelastography assessment with standard coagulation parameters postoperatively, and to assess thromboelastography in children with significant hemorrhage.
  
  
  METHODS
  Sixty patients requiring cardiopulmonary bypass were enrolled in a prospective observational study of perioperative thromboelastography. Thromboelastography measures were obtained preoperatively, intraoperatively after protamine administration, upon admit to the intensive care unit, and when patients were treated for bleeding. Thromboelastography measures were not used for clinical care. Postoperative thromboelastography measurements were compared with the standard coagulation parameters. Intraoperative thromboelastography, postoperative thromboelastography, and clinical outcomes were compared among patients who did and did not have significant postoperative bleeding.
  
  
  RESULTS
  Preoperative thromboelastography parameters were similar to other published normal values for pediatric patients. Transfusion recommendations based on thromboelastography measurements were significantly different from those based on the standard coagulation testing. Thromboelastography measures after initial protamine administration were significantly different in patients with postoperative bleeding. This difference was not present upon arrival to the intensive care unit. Patients with significant bleeding tended to cease bleeding when clinical interventions were in agreement with recommendations based on thromboelastography.
  
  
  CONCLUSIONS
  Pediatric patients with significant postoperative bleeding after surgery are more likely to have abnormal thromboelastography early after cessation of cardiopulmonary bypass. Thromboelastography illustrates derangements in the coagulation system and may aid in the treatment of postoperative bleeding.
authors.affiliation: Department of Pediatrics, Division of Critical Care, Medical College of Wisconsin, Milwaukee, WI, USA.
authors.forename: Robert A
authors.initials: RA
authors.lastname: Niebler
authors.forename: Joan C
authors.initials: JC
authors.lastname: Gill
authors.forename: Christopher P
authors.initials: CP
authors.lastname: Brabant
authors.forename: Michael E
authors.initials: ME
authors.lastname: Mitchell
authors.forename: Melodee
authors.initials: M
authors.lastname: Nugent
authors.forename: Pippa
authors.initials: P
authors.lastname: Simpson
authors.forename: James S
authors.initials: JS
authors.lastname: Tweddell
authors.forename: Nancy S
authors.initials: NS
authors.lastname: Ghanayem
keywords: blood; blood transfusion; coagulation/anticoagulation; congenital heart surgery; hematology; postoperative care